Case Report: Zen meditation-integrated CBT normalized the impaired brain function of a chronic low back pain patient—from the findings of brain blood flow SPECT imaging

Tetsumi Honda

doi:10.12688/f1000research.126031.1

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Case Report

Case Report: Zen meditation-integrated CBT normalized the impaired brain function of a chronic low back pain patient—from the findings of brain blood flow SPECT imaging

[version 1; peer review: 1 approved, 1 not approved]

Tetsumi Honda

PUBLISHED 25 Nov 2022

Author details Author details

Department of Rehabilitation Medicine, Rizankai Iida Hospital, Nagano, 395-8505, Japan

Tetsumi Honda
Roles: Investigation, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background: Mindfulness meditation for chronic pain is popular globally, but evidence of its efficacy is limited. Moreover, there are no established methods on the objective evaluation of the effectiveness of interventions for chronic pain. In this study, a chronic low back pain patient was treated with traditional Japanese Buddhism meditation-integrated cognitive behavioral therapy and the pre- and post-intervention brain single-photon emission computed tomography (SPECT) images were compared.
Case: A 45-year-old man was experiencing continuous back pain after a vehicular accident and experienced insufficient improvement after drug treatment. The patient underwent a 3-month outpatient mindfulness meditation-integrated cognitive behavioral therapy program executed by a multidisciplinary team: physician visits (once a week for 30 min), multidisciplinary medical and meditation education (Zen breath counting meditation and mantra), physiotherapy interventions (twice weekly), occupational therapy interventions (twice weekly), psychiatric occupational therapy interventions (twice weekly), and nutritional interventions (twice weekly). After treatment, the patient reported a decrease in subjective pain overall, based on whether or not a pain attack occurred. Brain SPECT imaging revealed an improvement in excess blood flow from the right temporoparietal junction to the inferior parietal lobe.
Conclusions: These findings indicate that Zen meditation is an effective intervention method for chronic pain and SPECT is a useful tool for measuring its effectiveness.

Keywords

chronic pain, mindfulness, Zen meditation, cognitive behavioral therapy, brain single-photon emission computed tomography

Corresponding author: Tetsumi Honda

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2022 Honda T. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Honda T. Case Report: Zen meditation-integrated CBT normalized the impaired brain function of a chronic low back pain patient—from the findings of brain blood flow SPECT imaging [version 1; peer review: 1 approved, 1 not approved]. F1000Research 2022, 11:1384 (https://doi.org/10.12688/f1000research.126031.1) First published: 25 Nov 2022, 11:1384 (https://doi.org/10.12688/f1000research.126031.1) Latest published: 25 Nov 2022, 11:1384 (https://doi.org/10.12688/f1000research.126031.1)

Introduction

In Japan, chronic pain is a highly prevalent (26.4%) major health care issue.¹ In 2012, Ogawa et al. reported that 72.4% patients discontinue treatment provided by health care providers due to treatment ineffectiveness.¹

Chronic pain is now considered a dysfunction of the central nervous system.²^–⁴ A number of neuroimaging techniques developed to evaluate chronic pain have revealed reconstructions³^,⁵ and changes in the networks³^,⁶ of the brains of patients with chronic pain; however, data on the efficacy of neuroimaging techniques in real-life clinical conditions are scarce.⁷ It is important to conduct studies evaluating brain biomarkers of pain to assess their behavior at the individual level.⁷

Various therapeutic approaches, including cognitive behavioral therapy (CBT),⁸^–¹¹ exercise therapy,¹¹^,¹² multidisciplinary approach,¹¹^–¹⁴ and mindfulness meditation¹¹^,¹⁵^,¹⁶ have been shown to be effective for chronic pain, and combination treatment with these approaches has been recommended.¹⁷ However, none of these approaches have included the practice of Zen meditation in their programs.

In this case, we utilized single-photon emission computed tomography (SPECT) of the brain alongside Zen meditation-integrated CBT provided by a multidisciplinary team. We assessed the pre- and post-intervention changes in the brain scans as well as in physical, psychological, and quality of life (QoL) tests.

Case report

Case presentation

The patient, a 45-year-old Japanese male taxi driver collided with a passenger vehicle in November 2015 and he bruised his back. Since then, he had been experiencing continuous back pain. Due to the frequent pain attacks, he sought relief through orthopedic surgery, massage, and osteopathy. In July 2019, he was referred to us by the rehabilitation department of a university hospital. The patient’s medical history included head trauma when he was 10 years old, bruising on the head, and 5-day hospitalization due to an unknown cause. He complained about cramp-like pain all over the paraspinal muscles on both sides of the back, which was centered on L4-5. There was no sensory impairment in the lower limbs, muscle atrophy, or the Lasègue’s sign, and the deep tendon reflex was normal. Simple lumbar spine radiographs and lumbar spine magnetic resonance imaging (MRI) showed no abnormalities.

Based on the aforementioned clinical and imaging findings, the patient was diagnosed with nonspecific chronic low back pain.

Investigations

Pre- and post-intervention evaluations included: (1) brain SPECT with 99mTc-ethyl cysteinate dimer and two-tailed view analysis using the easy Z-score imaging system (eZIS)¹⁸ (August 1, 2019 and April 10, 2020); (2) a pain diary in which the degree of pain was recorded using the Numerical Rating Scale (NRS) every hour for 1 week before the intervention and before/after the program (scores calculated as the daily average at the time of an attack and at the time of no attack); and (3) psychological, QoL, and physical strength examinations, including the Pain Catastrophic Scale (Japanese version),¹⁹ Pain Self-Efficacy Questionnaire (Japanese version),²⁰ Beck Depression Inventory,²¹ 12-item Short Form Health Survey (Japanese version),²² and physical strength examinations.²³^,²⁴

Treatment

The pre-intervention period was from October 3 to December 21, 2019. During the pre-intervention period, the effectiveness of pharmacotherapy was verified. Duloxetine has been tested in several randomized control trials (RCTs) for chronic low back pain²⁵^,²⁶ and is strongly recommended in systematic reviews.²⁷^,²⁸ In this case, duloxetine use was initiated from the initial consultation, with dosage increases each week from 20 mg/day to 60 mg/day. The patient was administered three tablets daily, ingested orally after each meal, starting with breakfast. As the drug administration alone did not lead to sufficient improvement, a 3-month Zen meditation-integrated CBT outpatient program was conducted. The intervention period was from January 8 to March 26, 2020. Before commencement of physician visits (once a week for 30 min), a brain SPECT eZIS image was obtained, and a treatment agreement was decided on with the goal of “normalization of brain function,” instead of healing of pain. During the program, drug administration was continued, and guidance was provided in terms of medical education about pain and breathing methods. The patient was advised to practice Zen breath counting meditation for 15 min twice a day with the following mantra “Leave pain alone. Do not fight against or escape from pain. Enjoy a bright and cheerful life” (Supplementary Video 1, which can be found as Extended data⁴⁴). His physician was a certified rehabilitation doctor of the Japanese Association of Rehabilitation Medicine and a licensed Buddhism priest who had practiced meditation for 40 years. Twice weekly physiotherapy interventions, in addition to actual physical therapy sessions, provided guidance on stretches to be performed at home and on a training plan involving walking. During twice weekly occupational therapy sessions, guidance was provided on body mechanics as well as an activity for application (“bookshelf construction”). Counselling and yoga sessions were conducted twice a week by the psychiatric occupational therapy team. The Department of Nutrition conducted dietary checks twice a week and provided nutritional guidance. During the course of the treatment, a conference was held by the members of the multidisciplinary team once a week to present information and to allow for optimal patient support. Pre-intervention and post-intervention examples can be found as Supplementary Videos 2 and 3 in Extended data.⁴⁴

Outcome and follow-up

Subjective pain (NRS score) decreased both at the time of an attack and no attack. All test values were maintained or improved (Table 1).

Table 1. Results of the tests.

Tests	Results	Intervention
Tests	Results	Pre-	Post-
Magnitudes of Pain (NRS)	Attack phase	9.3	7.8
	Non-attack phase	3.8	3
Psychological/QoL Tests	BDI	18	10
	Pain Catastrophizing Scale
	Comprising rumination	20	13
	Helplessness	7	6
	Magnification	7	4
	Pain Self-Efficacy Scale	34/60	55/60
	SF-12
	PCS	25.1	46.9
	MCS	48.9	51.7
	RCS	52.9	51.4
Physical Strength Tests	Grip strength (right/left) (kg)	21.3/31.1	31.2/29.7
	One foot standing (right/left) (s)	22/14	66/61
	Functional Reach test (cm)	31	38.5
	Berg Balance Scale	56	56
	Uplift test (times)	5	9
	Sit forward test (cm)	23	39
	Side jump test (times)	14	26
	5-min walking (m)	74.9	268.1
	Timed up and go test (s)	7.7	5.6

The brain SPECT (eZIS) examination revealed that excess blood flow from the right temporoparietal junction (TPJ) to the inferior parietal lobe (IPL) had improved (Figures 1 and 2).

Figure 1. Brain SPECT (eZIS) examination on August 1, 2019 (pre-intervention).

Blood flow was decreased in the bilateral dorsolateral frontal lobe and increased in the IPL, anterior insula, and temporal lobe centered on the right TPJ. SPECT = single-photon emission computed tomography; eZIS = easy Z-score imaging system; IPL = inferior parietal lobe.

Figure 2. Brain SPECT (eZIS) examination on April 10, 2020 (post-intervention).

The brain SPECT (eZIS) examination revealed that excess blood flow from the right TPJ to the IPL has improved. SPECT = single-photon emission computed tomography; eZIS = easy Z-score imaging system; TPJ = temporoparietal junction; IPL = inferior parietal lobe.

At the follow-up visit to our clinic, the patient could walk without crutches after 3 months and could run after 4 months of the program (Supplementary Videos 4 and 5, which can be found as Extended data⁴⁴).

Discussion

Mindfulness meditation for chronic pain is popular globally, but evidence of its efficacy is limited.¹⁶^,²⁹^,³⁰ In the case, Zen meditation-integrated CBT was found to be effective for improving chronic pain, as evidenced by improvements in excess regional cerebral blood flow and improvements in subjective pain scores.

The brain SPECT findings before the intervention showed decreased blood flow in the bilateral dorsolateral frontal lobe and extensive increased blood flow in the IPL, anterior insula, and temporal lobe, centered on the right TPJ. Previous studies on cerebral blood flow in chronic pain have highlighted hyperperfusion of the somatosensory cortex and hypoperfusion of the frontal, cingulate, medial temporal, and cerebellar cortices in patients with hyperalgesic fibromyalgia.³¹ We have previously reported decreased blood flow in the bilateral dorsolateral prefrontal cortex and increased blood flow in the parietal lobe and cerebellum in patients with chronic low back pain.³²

Using MRI, decreased grey matter density in the prefrontal cortex and thalamus has been reported.⁵ The development of functional connectivity MRI has revealed that the right TPJ is the core region of the salience network (SN), and that the IPL is the core region of the default mode network (DMN).³³^,³⁴ In chronic pain, the brain functional network at rest is impaired, and the DMN and SN are in a fused state.³⁵ Additionally, Doll et al. reported that more mindful individuals show a stronger negative correlation between the DMN and SN.³⁶ In this case report, improved clinical test results and normalization of cerebral blood flow in the right TPJ and IPL by SPECT are consistent with the aforementioned hypothesis.

Zen breath counting is a traditional Buddhism mindfulness practice in Japan and was integrated into the program. While practicing Zen breath counting meditation, the participants are trained to “Let random thoughts arise and vanish as they will. Do not dally with them and do not try to expel them, but merely concentrate on counting your breath” by the master.³⁷ We reformed this mantra to “Leave pain alone. Do not fight against or escape from pain, but merely concentrate on enjoying a bright and cheerful life.”

A common issue in pain management programs is the motivation of patients to engage in the program.³⁸^,³⁹ From a behavioral therapy standpoint, the principle is that staff should be nonresponsive to the pain behavior to avoid reinforcing the patient's pain behaviors.⁴⁰ However, this attitude often jeopardizes the therapist-patient relationship and leads to treatment interruptions.

In this program, we presented brain SPECT images to the patient before the start of the program and highlighted the overactivity of the right TPJ. To normalize the brain function and to reduce the unconscious focus of attention on pain, the staff advised against responding to the pain behavior. In addition to teaching, various skills including physical exercises, body mechanics to prevent pain, nutritional managements, and breath counting meditation, a multidisciplinary team support during the program resulted in the reduction of subjective pain, behavioral change, and improvement of brain function by increasing physical activity and development of the ability to practice applied activities by the patient in his daily life.

In terms of the limitations of the study, the improvement in the NRS score in this case was 0.8 at the time of no attack and 1.5 at the time of attack (Table 1). It has been noted that the change in the NRS score must be higher than or equal to 2 to objectively assess the improvement in pain⁴¹; however, this study did not include physical function as a marker of validity. According to the multifaceted model of pain,⁴² pain is composed of not only nociception from the peripheral tissue but also pain sensation in the nervous system, suffering in the brain, and pain behavior that the patient expresses. According to this model, verbal responses alone are not sufficient for objective assessment of pain, and improvements in physical activity should also considered. In this case study, the physical strength examination results showed significant improvement (Table 1); therefore, it is appropriate to judge that the intervention was effective, although the change in the NRS score was less than 2.

Chronic pain can last for 6 or more months.⁴³ Because the pain is spread across all parts of the body, not all chronic pain presents with a uniform cerebral blood flow state. Differing findings on cerebellar blood flow on SPECT have been reported.³¹^,³² The possibility that blood flow status may be altered by the period after the onset of chronic pain cannot be ruled out. Hence, it is necessary to investigate more cases in the future.

In addition to Zen meditation, the program included exercise therapy, rehabilitation, cognitive therapy, yoga, and a multidisciplinary approach in parallel. It is a challenge to explore the effectiveness of different therapy strategies for chronic pain patients by analyzing the effect of specific interventions on the brain morphologically and functional alternations, as well as on clinical measures of pain.³

To the best of our knowledge, this is the first report that has implemented Zen meditation to the therapy program for patients with chronic pain, and the first to use brain imaging for assessment of its effectiveness.

Patient’s perspective

“Before this program, my back hurt irregularly every day and I could not keep standing. I was in so much pain that I could not even walk. It was painful all over my body when the weather was bad. I could not carry anything heavy when I was shopping. I could not go out for a long period of time by myself.

The back pain that appeared irregularly every day was painful, and it was hard not knowing if it would ever go away. I thought that I would never get better; it was hard. I could not see the future. It hurt, because of which I tried to not do any activities and only lie on the bed as still as possible.

However, after this program, I am only in pain once or twice a week, which is not as bad as before. Strong pain in the back appears once or twice a week. When the weather is bad, my body is sluggish, and my joints hurt.

I can run a little bit. Overall, I am in a good condition. Now, I can go out on my own.

If I take the worst pain days as 100, my pain is 35 now.

To continue and to maintain the recovery I have had, I am aware of taking three meals regularly, losing weight, and continuing to walk and train daily. I am going to do my best without getting bogged down.

When the back pain appears, I will start moving and find out what I can do, instead of staying still and putting up with the pain.”

Consent

Written informed consent for publication of their clinical details and clinical images was obtained from the patient.

Data availability

Underlying data

All data underlying the results are available as part of the article and no additional source data are required.

Extended data

Figshare: Case Report: Zen meditation-integrated CBT normalized the impaired brain function of a chronic low back pain patient—from the findings of brain blood flow SPECT imaging. https://doi.org/10.6084/m9.figshare.21431493.⁴⁴

This project contains the following extended data:

- Sample_video_1.mp4
- Sample_video_2.mp4
- Sample_video_3.mp4
- Sample_video_4.mp4
- Sample_video_5.mp4

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgments

I would like to thank Editage (www.editage.com) for English language editing. They have provided permission for acknowledgment.

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Comments on this article Comments (0)

Version 1

VERSION 1 PUBLISHED 25 Nov 2022

Author details Author details

Department of Rehabilitation Medicine, Rizankai Iida Hospital, Nagano, 395-8505, Japan

Tetsumi Honda
Roles: Investigation, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (1)

version 1

Published: 25 Nov 2022, 11:1384

https://doi.org/10.12688/f1000research.126031.1

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© 2022 Honda T. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Honda T. Case Report: Zen meditation-integrated CBT normalized the impaired brain function of a chronic low back pain patient—from the findings of brain blood flow SPECT imaging [version 1; peer review: 1 approved, 1 not approved]. F1000Research 2022, 11:1384 (https://doi.org/10.12688/f1000research.126031.1)

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Open Peer Review

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VERSION 1

PUBLISHED 25 Nov 2022

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Reviewer Report 29 Aug 2024

Arman Yurisaldi Saleh, Universitas Pembangunan Nasional Veteran Jakarta, Jakarta, Special Capital Region of Jakarta, Indonesia

Approved

https://doi.org/10.5256/f1000research.138404.r254953

The contents of the journal are short, concise and clear.

This research is rare and uses advanced technology. Even if it is only one research subject. It is worth considering so that similar research can be carried ... Continue reading

The contents of the journal are short, concise and clear.

This research is rare and uses advanced technology. Even if it is only one research subject. It is worth considering so that similar research can be carried out in other settings to confirm the results they obtained

Based on the abstract, the researcher explains quite concisely and clearly.

Minor points that the future needs to be added are related to past history.

It can be concluded that in this case, the patient's pain complaints were more caused by neuropsychiatric disorders considering that the patient had a head injury when he was 10 years old, the type of head injury that had been experienced (degree of head injury) was not explained.

While the results of the neurological examination were within normal limits and the results of the lumbar MRI did not find any abnormalities.

The major points of the advantages of this study are:
The study conducted has the advantage that it is the first time it has been conducted on zen meditation practitioners with SPECT even though the subject is only 1 person (single trial), pre-post intervention can be proven valid.

The therapy schedule is such that it is carried out by multiple experts and can be carried out and imitated to confirm the results elsewhere so that it is replicable.
The study can be used as an example for other researchers related to zen meditation.

Is the background of the case’s history and progression described in sufficient detail?

Yes
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Yes
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Yes
Is the case presented with sufficient detail to be useful for other practitioners?

Yes

References

1. Honda T: Case Report: Zen meditation-integrated CBT normalized the impaired brain function of a chronic low back pain patient—from the findings of brain blood flow SPECT imaging. F1000Research. 2022; 11. Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Neurology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report 07 May 2024

Prem Venkatesan, Manipal College of Health Professionals, Manipal, India

Not Approved

https://doi.org/10.5256/f1000research.138404.r267381

Dear Editor,
Thanks for providing me the opportunity to review the manuscript titled: " Case Report: Zen meditation-integrated CBT normalized the impaired brain function of a chronic low back pain patient—from the findings of brain blood flow SPECT imaging "
... Continue reading

Dear Editor,
Thanks for providing me the opportunity to review the manuscript titled: " Case Report: Zen meditation-integrated CBT normalized the impaired brain function of a chronic low back pain patient—from the findings of brain blood flow SPECT imaging "
I really enjoyed reviewing the manuscript. But I have a few concerns which I am listing below.

Abstract
1. Highlight the key findings.
2. Conclusion is inconclusive.

Introduction.
1. Currently huge body of evidence is available on the effects of mindfulness and brain (Mindfulness-based therapy improves brain functional network reconfiguration efficiency Transl Psychiatry. 2023 Nov 11;13(1):345. [Ref:1], hence what is the need to do case report
2. How Zen meditation is different from mindfulness therapy like above reference?
3. The introduction is written with facts but lacks continuity and hence not properly leading to the need of the study.

Methods:
1.The presentation of case report is detailed but it creates a confusion while reading as the past history and present history are written together.
2. The study has examined a good number of parameters but what is the justification for not including the muscle strength assessment.
3. Can you provide details of exercise provided to patients- its type of exercise, intensity, time and progression.
4. Author can provide details about type of yoga, pranayamas, asanas and meditation practiced by the patients. Also duration, frequency and progression of yoga.
The following study demonstrated effectiveness of yoga and Brain, hence how to justify improvement is due to Zen meditation and not due to components of yoga. (A feasibility study on yoga’s mechanism of action for chronic low back pain: psychological and neurophysiological changes, including global gene expression and DNA methylation, following a yoga intervention for chronic low back pain. Pilot Feasibility Stud. 2022; 8: 142)
5. Authors can provide details of the Nutrition.
6. Authors can provide details of Cognitive behavioral therapy.
7. Existing studies have provided evidence of CBT on the brain areas “Neural Effects of Cognitive Behavioral Therapy in Psychiatric Disorders: A Systematic Review and Activation Likelihood Estimation Meta-Analysis. Front Psychol. 2022; 13: 853804”, hence how do you justify the effect of Zen meditation.
8. Authors have addressed psychological tests and physical tests.
9. What is the hypothesis linking Zen meditation and physical tests improvement
10. The values pertaining to the blood flow in the areas of brain is missing and also it needs to be explained with the effect size so as to justify the result.
11. Details regarding the usage of any Guidelines for reporting Case Report is missing.

Discussion
1. A few terms has appeared in the discussion part which was nowhere mentioned in the introduction or in any part of the manuscript and hence it will be difficult for the readers to connect to the idea that the author tries to explain
2. Pain is the primary outcome and it has only been reduced below the effect size mark, hence the result of this technique has to be justified with a more evidences.
3. Although discussion is done on the key findings there is a need for more literature to support the findings.

Is the background of the case’s history and progression described in sufficient detail?

No
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Partly
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Partly
Is the case presented with sufficient detail to be useful for other practitioners?

No

References

1. Yue WL, Ng KK, Koh AJ, Perini F, et al.: Mindfulness-based therapy improves brain functional network reconfiguration efficiency.Transl Psychiatry. 2023; 13 (1): 345 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: chronic pain, rehabilitation

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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VERSION 1 PUBLISHED 25 Nov 2022

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Version 1 25 Nov 22	read	read

Prem Venkatesan, Manipal College of Health Professionals, Manipal, India
Arman Yurisaldi Saleh, Universitas Pembangunan Nasional Veteran Jakarta, Jakarta, Indonesia

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Reviewer Report

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29 Aug 2024 | for Version 1

Arman Yurisaldi Saleh, Universitas Pembangunan Nasional Veteran Jakarta, Jakarta, Special Capital Region of Jakarta, Indonesia

12 Views Cite this report Responses(0)

Approved

The contents of the journal are short, concise and clear.

This research is rare and uses advanced technology. Even if it is only one research subject. It is worth considering so that similar research can be carried out in other settings to confirm the results they obtained

Based on the abstract, the researcher explains quite concisely and clearly.

Minor points that the future needs to be added are related to past history.

It can be concluded that in this case, the patient's pain complaints were more caused by neuropsychiatric disorders considering that the patient had a head injury when he was 10 years old, the type of head injury that had been experienced (degree of head injury) was not explained.

While the results of the neurological examination were within normal limits and the results of the lumbar MRI did not find any abnormalities.

The major points of the advantages of this study are:
The study conducted has the advantage that it is the first time it has been conducted on zen meditation practitioners with SPECT even though the subject is only 1 person (single trial), pre-post intervention can be proven valid.

The therapy schedule is such that it is carried out by multiple experts and can be carried out and imitated to confirm the results elsewhere so that it is replicable.
The study can be used as an example for other researchers related to zen meditation.

Is the background of the case’s history and progression described in sufficient detail?

Yes
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Yes
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Yes
Is the case presented with sufficient detail to be useful for other practitioners?

Yes

References

1. Honda T: Case Report: Zen meditation-integrated CBT normalized the impaired brain function of a chronic low back pain patient—from the findings of brain blood flow SPECT imaging. F1000Research. 2022; 11. Publisher Full Text

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Neurology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

11 Views

07 May 2024 | for Version 1

Prem Venkatesan, Manipal College of Health Professionals, Manipal, India

11 Views Cite this report Responses(0)

Not Approved

Dear Editor,
Thanks for providing me the opportunity to review the manuscript titled: " Case Report: Zen meditation-integrated CBT normalized the impaired brain function of a chronic low back pain patient—from the findings of brain blood flow SPECT imaging "
I really enjoyed reviewing the manuscript. But I have a few concerns which I am listing below.

Abstract
1. Highlight the key findings.
2. Conclusion is inconclusive.

Introduction.
1. Currently huge body of evidence is available on the effects of mindfulness and brain (Mindfulness-based therapy improves brain functional network reconfiguration efficiency Transl Psychiatry. 2023 Nov 11;13(1):345. [Ref:1], hence what is the need to do case report
2. How Zen meditation is different from mindfulness therapy like above reference?
3. The introduction is written with facts but lacks continuity and hence not properly leading to the need of the study.

Methods:
1.The presentation of case report is detailed but it creates a confusion while reading as the past history and present history are written together.
2. The study has examined a good number of parameters but what is the justification for not including the muscle strength assessment.
3. Can you provide details of exercise provided to patients- its type of exercise, intensity, time and progression.
4. Author can provide details about type of yoga, pranayamas, asanas and meditation practiced by the patients. Also duration, frequency and progression of yoga.
The following study demonstrated effectiveness of yoga and Brain, hence how to justify improvement is due to Zen meditation and not due to components of yoga. (A feasibility study on yoga’s mechanism of action for chronic low back pain: psychological and neurophysiological changes, including global gene expression and DNA methylation, following a yoga intervention for chronic low back pain. Pilot Feasibility Stud. 2022; 8: 142)
5. Authors can provide details of the Nutrition.
6. Authors can provide details of Cognitive behavioral therapy.
7. Existing studies have provided evidence of CBT on the brain areas “Neural Effects of Cognitive Behavioral Therapy in Psychiatric Disorders: A Systematic Review and Activation Likelihood Estimation Meta-Analysis. Front Psychol. 2022; 13: 853804”, hence how do you justify the effect of Zen meditation.
8. Authors have addressed psychological tests and physical tests.
9. What is the hypothesis linking Zen meditation and physical tests improvement
10. The values pertaining to the blood flow in the areas of brain is missing and also it needs to be explained with the effect size so as to justify the result.
11. Details regarding the usage of any Guidelines for reporting Case Report is missing.

Discussion
1. A few terms has appeared in the discussion part which was nowhere mentioned in the introduction or in any part of the manuscript and hence it will be difficult for the readers to connect to the idea that the author tries to explain
2. Pain is the primary outcome and it has only been reduced below the effect size mark, hence the result of this technique has to be justified with a more evidences.
3. Although discussion is done on the key findings there is a need for more literature to support the findings.

Is the background of the case’s history and progression described in sufficient detail?

No
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Partly
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Partly
Is the case presented with sufficient detail to be useful for other practitioners?

No

References

1. Yue WL, Ng KK, Koh AJ, Perini F, et al.: Mindfulness-based therapy improves brain functional network reconfiguration efficiency.Transl Psychiatry. 2023; 13 (1): 345 PubMed Abstract | Publisher Full Text

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

chronic pain, rehabilitation

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

Respond to this report

Responses (0)

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Case Report: Zen meditation-integrated CBT normalized the impaired brain function of a chronic low back pain patient—from the findings of brain blood flow SPECT imaging

Abstract

Keywords

Introduction

Case report

Case presentation

Investigations

Treatment

Outcome and follow-up

Table 1. Results of the tests.

Figure 1. Brain SPECT (eZIS) examination on August 1, 2019 (pre-intervention).

Figure 2. Brain SPECT (eZIS) examination on April 10, 2020 (post-intervention).

Discussion

Patient’s perspective

Consent

Data availability

Underlying data

Extended data

Acknowledgments

References

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